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} 141 q 5c Ii <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE GP�EERMIT Www.S Ov.or /ehd EXPIRES <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS oc 4/ ,�f CITY/ZIP L&;/ I5z 42 m <br /> n c '7 D <br /> CROSS STREET PO' 1" APN O�5 t% y Q��(�PARCEL SIZE U4 f'�AAND USE APPLICATION# p <br /> OWNER NAME �Z_LC-1HONE cn <br /> OWNER ADDRESS 7 CITY/STATE/ZIP' <br /> CONTRACTOR /V?,?1( c r< n PDQ " PHONE <br /> CONTRACTOR ADDRESS G Z CITY/STATE/ZIP L_111)', C, <br /> SUBCONTRACTOR/CONSULTANTl/ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS /1 - CITY/STATE/ZIP <br /> LICENSE 17�C-57 C-61 D-09 ❑ Other NUMBER t t f C C l EXPIRATION DATE <br /> BILLING PARTY: 7 OWNER ICONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)El Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring XSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well , Replacement Well - Well Alteration/Modification = Other <br /> F Monitoring Well(s) #of wells Soil Boring(s) a of borings ,(Geotechnical _#of borings <br /> ❑ Out-Of-Service Well L Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump Pump Replacement I Pump Repair a Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method , Mud Rotary I Air Rotary Auger i Cable Tool Push Point Other <br /> Proposed Well Depth �b ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft pj� <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched - Steel - Plastic - Stainless Steel - Other ^^1I <br /> Grout Seal Depth ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped _ Free Fall _ Other L Retardant/Accelerator(name) n <br /> PEDESTAL Installed By Driller I Pump Contractor Other ;L% <br /> �J <br /> _ Concrete Pedestal _Dimensions:Width ft Length ft Thick in L Christy Box <br /> PUMP Submersible Turbine I Other HP Pump Set ft Standing Water Level �9 <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN T <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANC NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7f69/7 <br /> SIGNED TITLE 7 1 i in t°rt" DATE <br /> i <br /> Lz <br /> r <br /> a c' <br /> D A M E N T U\ E ON L Y <br /> I <br /> Application Accepted By Date Area Employee ID# <br /> A,&— <br /> Grout Inspection By Date *PECIAL Well Permit <br /> Pump Inspection By ill Date WAIVER Received <br /> Soil Boring Inspection By f Date L Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By as Remitted Service Request# <br /> Pb 8 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />